The Values of Health Reform

Rosemary Flanigan
June 29, 2009

The new Hastings Center REPORT is focused on health reform, from the perspective of VALUES. (“Connecting American Values with Health Reform”)

Notice the “health,” not “healthcare.”

Erika Blacksher, formerly of the Center and now with Hastings Center, sees “Health” as the value at stake—healthCARE is ”but one determinant of health, and by some measures it is a relatively minor one.”

It’s an interesting way to get people to focus on reform:

Bruce Jennings writes on LIBERTY; Paul Menzel on JUSTICE AND FAIRNESS in mandating universal participation; Jim Sabin on RESPONSIBILITY (in which he contrasts Joey Starrett and Shane the cowboy in the movie); William Sage on SOLIDARITY (it is good to hear talk of “public good” in this economic downturn time); Dan Callahan on MEDICAL PROGRESS (and its unintended consequences—Dan is still beating that drum); Lawrence Gostin on PRIVACY (and how the prevailing model fails to protect it); Ed Pellegrino on PHYSICIAN INTEGRITY (what else?); Frank Davidoff on QUALITY, and Marc Roberts on EFFICIENCY.

I’ll be telling you some of my thoughts. Overall, I like anchoring reform in something besides economics. More later—unless one or other of you has read the issue and want to get a headstart. THANKS.

"Because that's what we do here..."

Rosemary Flanigan
June 26, 2009

The June 23 Time magazine has an article on healthcare reform (Michael Grunwald’s “How to Cut Health-Care Costs: Less Care, More Data”)which begins with a story about Ezekiel Emanuel, who spoke here in KC two years ago on pandemic policies, and is now near brother Rahm in the Obama White House.

The article says, “Ezekiel Emanuel got a memorable introduction to our haphazard health-care system on his first visit to a cancer ward as a medical student. The white coats were ordering a transfusion for a teenage girl, and since shyness does not run in his family. . . .he interrupted to ask why.

Because she had Hodgkin’s disease and her platelets were below 20,000, the team explained.

Emanuel still had questions: Was there evidence for that protocol? Don’t some hospitals wait until 10,000? Why 20,000? Because that’s what we do here, one doc replied.”

“Because that’s what we do here. . . .”

I am reminded of those years I taught undergraduates that to cling stubbornly to the status quo was immoral.

I won’t hastily judge the “immoral” part—but I will question if our healthcare professionals, like banking, insurance, investing professionals, realize that “the unexamined habits of one’s profession are not worth continuing.” (With apologies to Socrates.)

Will the rich resources of reflective ethics committee members be tapped when professionals need to reconsider “that’s what we do here” in the age of reform?

The End of Life Equation

Center for Practical Bioethics advising Congress, Institute of Medicine and the Commonwealth Fund on end of life initiatives

President Barack Obama, in a June 24 town hall meeting on healthcare reform, said he does not want to see bureaucracies making end of life decisions. At the same time, healthcare reform will not solve every difficult problem with end of life care. “We as a culture and as a society have to start making better decisions within our own families and ourselves,” he said.

The Center for Practical Bioethics has been working toward the goal of better decision making at the end of life for more than two decades. Three current developments highlight the Center’s role and impact in these critical policy areas:

1. On Monday, June 22 the Center, in collaboration with RAND Health and the US Department of Health and Human Services, delivered a report to Congress on advance directives and advance care planning. It’s the largest study ever done on the efficacy of advance care planning and recommends changes in policy to improve end of life planning. (Link to report here.)

2. This Saturday, June 27 John Carney, the Center’s Vice President for Aging and End of Life will speak at a policy conference sponsored by the Commonwealth Fund focusing on two important issues: the intersection of long-term care and end-of-life care and long-term care financing reform.

3. Next month, Myra Christopher, Center President and CEO, will join 35 leading clinicians, payers, policymakers and consumers at the Institute of Medicine to develop a model to empower patients and improve care for those with advanced illness.

“The Center has a 25 year track record of working in this arena,” Christopher says. “Now is a critical time to find common ground on what we ought to do to provide quality care in an equitable fashion for the seriously ill and dying.”

The Ethics of Care for Undocumented Immigrants

Sharon Lee, MD
David Grummon, JD

15 minutes 11 seconds

What’s the ethical case for care of undocumented immigrants? In this edition of The Bioethics Channel, Dr. Sharon Lee, director of a safety net clinic in Kansas City, Kansas and attorney David Grummon discuss how should we talk about and address this challenge.

THE "R" WORD -- RATIONING!

John Lantos, MD
June 19, 2009

Milton Friedman said, famously, that there is no such thing as a free lunch.

That’s true. The real question in health care rationing is related, but different. Who gets to eat and who pays the bill?

Health care financing in the United States is largely based upon a system by which everybody feels that they aren’t paying, even though our health care costs are far higher, per capita, than in any other country in the world. They are about 30% higher than in every other industrialized country.

We are all paying for a lunch that is not only not free but in fact is vastly overpriced. But because nobody brings us the check, it feels free.

Our health care is paid for by insurance that is either funded by taxes or taken out of our paycheck by our employers (and that is also funded by taxes – that is, by tax exemptions) or, if we don’t have money or health insurance, we get health care that is funded by either taxes, in public hospitals, or by cross-subsidization from overcharging people who do have insurance.

The whole system is so fiendishly complicated that we spend 20% of our health care dollars just paying administrators whose job is to try to get more of those collective dollars flowing into their organization and fewer flowing out.

Health economist Uwe Reinhardt long ago elaborated on Friedman’s culinary analogy, and described the political debates over health reform as really being about “Table Manners at the Health Care Feast.”

He suggested that, in all discussions of rationing, we should ask not what sorts of medical treatments will be allocated to which patients but, instead, what sorts lifestyles will be allocated to which health care providers. That is still a useful way to think about the debates about rationing.

If we cut the costs of our health care system, someone will get less of something than they do now. Who will it be, and how much of what will they get less of? As always, the goal of our convoluted political discourse is to make it as hard as possible to answer those questions.

Link: Health Care Rationing Rhetoric Overlooks Reality, New York Times, June 17

Medical Futility Blog -- by Thaddeus Pope: Lawyers and Advance Directives

Medical Futility Blog -- by Thaddeus Pope: Lawyers and Advance Directives

Contradictions in Healthcare Delivery

Rosemary Flanigan
June 17, 2009

I recently gave a talk about the Center for Practical Bioethics at a really upscale retirement center (about 40 people came) and I surmised that every one of them had experienced the contradictions daily encountered when we enter the world of healthcare delivery: like “knowing” what to do, yet being without the energy to start over. Or becoming part of the fast track of aggressive care, yet knowing it is failing in what you hoped it could do.

Yet even with all their first-hand experiences, when push comes to shove, will they stand up for hospice care or aggressively implement their loved one’s wishes?

I heard one heartening story yesterday: a neighbor had called 911 and the son (who was the father’s surrogate decision-maker) heard that his dad was in the hospital. He went to the hospital, had his father checked out—because the dad had said he wanted to die at home and he was dying—and the ambulance that had brought him returned him home.

I call that story a good “shove.”

What has Karen Quinlan taught us?

Rosemary Flanigan

June 15, 2009

I was surprised by Lorell’s identifying June 11, 2009 as the 24th anniversary of Karen Quinlan’s death, nearly 10 years after being weaned from the respirator.

That news reminded me of being young—and still teaching—and how I used the “Matter of Quinlan. Supreme Court of New Jersey 1976” when I taught ethics. I wanted the students to see the best arguments on issues, whether pro or con—and this case was the best example of legal reasoning, supported by good philosophical distinctions, that I could find for end-of-life issues.

I hope the students all memorized this “holding”: “The State’s interest to maintain life weaken, and a patient’s right of privacy grows, as the degree of bodily invasion increases and as prognosis dims.” I think that’s brilliant—and I hope I said it often enough that it drilled a hole in their heads.

Using the ordinary/extraordinary means distinction and the distinction between direct killing and allowing to die, the Supreme Court Justices declared 7-0 “. . .upon the concurrence of the guardian and family of Karen, should the responsible attending physicians conclude that there is no reasonable possibility of Karen’s ever emerging from her present comatose condition to a cognitive, sapient state and that the life-support apparatus now being administered to Karen should be discontinued, they shall consult with the hospital ‘Ethics Committee’. . . .”

I wonder how long it took the hospital to get an “Ethics Committee” up and running!!

So many years later—so many trips to the courtroom. But I hope that responsible advance care planning has eliminated many other such trips.

The Algorithms of Arguing for Treatment of a Minor

Rosemary Flanigan
June 12, 2009

I’ve re-read the four articles in the Great Debates section of the recent Cambridge Quarterly, and I find it rather measured.

Lainie Friedman Ross from the U.of Chicago entitled hers “Arguments against Respecting a Minor’s Refusal of Efficacious Life-Saving Treatment” but I found few new arguments. If the therapies are “effective,” and the child says no (but the parents say Yes), then treat.

Respect parental wishes and try to convince the child to see the utility of the treatment.

If the parents say No and the child says No, then treat with a court order.

But when effective therapy does not exist, then if the parent says yes and the child says no, treat or don’t treat based on benefit-to-risk ratio and the maturity of the child. But if the parents say no but the child says yes to treatment, “Do not treat. When possible, seek compromise.”

And the same goes when the child and the parent both refuse the treatment.

I love the algorithms; if only “effective” and “ineffective” were as readily known!! It’s easier being the philosopher here than the pediatrician!!!

TV Series Seeking Stories on How We Die

A new TV series is looking for first-person stories from patients, their families, loved ones, and doctors about how personal experiences have shaped what we believe about death and dying, and about the decisions we make for ourselves, for loved ones, or for patients at the end of life.

The series will explore experiences that tested or challenged their values and beliefs about who decides when and how we die, and what role, if any, government and healthcare institutions should play in those decisions.

The series, tentatively titled "Stories," is being developed by Marc N. Weiss, creator of the long-running PBS series P.O.V. and Tom Yellin, a veteran network news and public affairs producer.

Here’s the website to submit your story: http://www.how-we-die.org

The project was created by Web Lab (www.weblab.org), an online laboratory designed to use the Web to engage people in new ways on a wide range of public and private issues, in collaboration with The Documentary Group (www.thedocumentarygroup.com), a production company founded by the core members of PJ Productions following the death of their colleague and partner, legendary broadcaster Peter Jennings.

Pallimed: A Hospice & Palliative Medicine Blog: 'Well, I’m still in a quandary over that...'

Pallimed: A Hospice & Palliative Medicine Blog: 'Well, I’m still in a quandary over that...'

Educating Our Emotions

Rosemary Flanigan
June 10, 2009

A recent column by David Brooks caught our attention. It’s entitled “The Empathy Issue” and discusses the role of emotion in judicial decisions. A friend suggested we substitute “judge” with “ethics committee person” and see how it reads.

The role of emotion’s interplay with reason has long fascinated philosophers and others. Even the substance or matter of ethics—our moral judgments—are strongly influenced by emotion. And the advice at the end is of paramount importance: it is not that we rely on emotion but how we educate our sentiments/emotions” within the bounds of manners and morals, tradition and practice.”

Right now I am having a hard time corralling my own emotions over the issue raised in the new Cambridge Quarterly, viz., adolescent decision-making. (I thought back in 1995 when Bill Bartholome shepherded the issue through Pediatrics that we sought adolescents’ assent along with their parents’ consent—a practice re-affirmed in 2006, that we had reached closure.)

Meanwhile, let’s think of educating our sentiments/emotions.

Link: The Empathy Issue, New York Times, May 29, 2009

The Ethics of Untreated Pain

Pain is too often left untreated ... and that's a serious public health issue.

In this edition of The Bioethics Channel, Dr. Richard Payne of Duke University's Institute for Care at the End of Life describes the scope of the problem and the obligations of medical professionals to treat pain.

Links:

Podcast: The Ethics of Untreated Pain, June 5, 2009, 15 minutes 37 seconds

Archive: The Bioethics Channel

The Bioethics Channel is a free podcast. To subscribe click on medicalchannelsonline.libsyn.com/rss.

Moral Judgements & Ethical Analysis

Rosemary Flanigan
June 4, 2009

Our ethics committee self-education segment today will be on justice—how it ties in with respect for persons, the different forms of justice (to help the members articulate their concerns) and then for a discussion piece, I have distributed an article by Dan Sulmasy (who will be our lecturer on August 6) recounting the story of the demise of seven out of eight Catholic hospitals in New York City in one year!

We don’t come close to having all the facts, but I am going to ask the committee to create possible moral judgments that might arise in one’s mind as we read the article.

First, because we use those moral judgments as the substance for ethical analysis, and second, because those moral judgments we spontaneously make reveal a lot about our meanings of justice. We shall be in the realm of perception, not reality—but we can still argue the justice/injustice of perceptions.

Can’t we???? HELP!!!

Bioethics Centers Celebrate Anniversaries

Rosemary Flanigan
June 2, 2009

We at the Center for Practical Bioethics just celebrated our 25th anniversary, and lo and behold! when the Hastings Center Report arrived this week-end, that venerable institution is celebrating its 40th!! So the 2009 issue reflects on the four ethical problems addressed 40 years ago: ethics and population, behavior control, the evolution of death and dying controversies, and deciphering genetics. And we’re STILL addressing them!

Robert M. Veatch (the first “employee” at Hastings Center) reflects on the death and dying controversies. One of the first task forces at the center was to disentangle the definition of death from decisions to forgo life support. But the task wasn’t an easy one and he thinks the brain-people and heart-people are mired in even more complexity today in their attempts to define death.

So, too, with forgoing life support or “allowing to die.” Even with federal legislation allowing us to refuse life-prolonging treatments, the questions that arise over appropriate surrogates, futile treatments, and resource allocation led the present staff to return to the Hastings Center’s early Guidelines on the Termination of Life-Sustaining Treatment to revise and update them in order to provide further assistance with these more nuanced issues.

It looks as if ethics centers will not be running out of things-to-do for quite some time!